Category Archives: General paediatrics

The EAT study

Allergy, General paediatrics, Immunology

2016 study of early introduction of six common food allergens into the diet of 1303 breastfed 3 month old infants recruited from a general (not high risk) population.

Randomized.  Breast feeding needed to be maintained until at least 5 months, at least 5 weeks of at least 75% of recommended dose (ie 3g of protein per week) between 3 and 6 months.

2g protein twice weekly was recommended – 2g is roughly:

  • 2 teaspoons peanut butter or 21 Bamba pieces
  • 1 small pot yogurt
  • 1/2 small egg
  • 10g fish
  • 1tsp tahini

In an intention to treat analysis, 7.1% of the standard introduction group (at parental discretion) and 5.6% of the early introduction group developed food allergy to one or more of the six intervention foods (peanuts, egg, cow’s milk, sesame, white fish and wheat) up to 3 years of age (p=0.32, ie no difference).

However, when the analysis was adjusted for adherence to early introduction, there was a statistically significant 67% lower rate of food allergy in the early introduction group (2.4% vs 6.4%; p=0.03), with no cases of peanut allergy (rate was 2.5% in control group) and 75% less egg allergy (1.4% vs 5.5%).  Rate of skin prick test positivity significantly lower for peanut, egg, milk, sesame.

Cooked egg works! Increasing dose, increasing effect.  Modelling suggests 2g protein weekly effective.

Safe!

However, poor adherence to the study protocol (only 32% managed to follow early introduction fully) highlights the challenges around introducing solids.

[Michael Perkins, DOI: 10.1056/NEJMoa1514210]

Cluster headache

General paediatrics, Neurology

Very rare – unilateral, orbital, supraorbital and/or temporal. Pain lasts 15-180mins but attacks occur multiple times a day (or at least on alternate days). Associated with autonomic features eg ipsilateral conjunctival injection, nasal congestion, forehead sweating, miosis, ptosis, agitation. Peak incidence in 20s, males predominate.

Can be episodic (bouts lasting 6-12 weeks every 1-2years) or else chronic.

Treat with high flow O2! Sumatriptan SC better than nasal, Zolmitriptan nasal preferred to oral or sumatriptan. Safe, licensed for kids.

Prophylaxis in adults is with verapamil!

Tension headache

Common, General paediatrics, Neurology, OPD

Tension headache

  • Mild to moderate rather than severe,
  • pressing or tightening rather than pulsatile,
  • Bilateral,
  • Not aggravated by routine physical activity.

Can be continuous. Phonophobia, photophobia, nausea are possible, but if more than one present, and particularly if vomiting or severe nausea, then migraine would be preferred diagnosis.

Often spreads into or arises from neck.

Chronic tension-type headache – as above but on >/15 days/month for at least 3 months. But gets messy – it is possible that a patient can have both this and Chronic migraine, viz only two of the four pain characteristics are present and associated with mild nausea. In all these cases consider Medication-overuse headache.

Idiopathic intracranial hypertension

General paediatrics, Neurology, Surgical

Previously “Benign” Intracranial Hypertension but not entirely benign…

Intracranial hypertension but with normal CSF, and no ventriculomegaly. Presents with usual symptoms of early morning headache, effortless vomiting. VI nerve palsy may be seen, rarely II/IV. Papilloedema is often the first clue.

No sex differential prepubertally, not associated with obesity (contrary to popular belief).

Normal CSF opening pressure is 7.5cm of water <2yr, 13.5 <5yr, 20 over 5yr. Lumbar puncture is therapeutic; 2 step tap procedure is usually used if opening pressure is over 30cm. NB General anaesthetic can give false pos result! Secondary causes include drugs, endocrine conditions.

Since repeated LP is unpleasant, medical therapy can be considered. Topiramate is probably equivalent to the more usual acetazolamide (a diuretic). Steroids should be used for malignant hypertension (ie where there is rapid progression). Any of these treatments may result in a low pressure headache.

Surgical options include Optic nerve sheath fenestration, lumbar-peritoneal shunt.

Headache

Common, General paediatrics, Neurology, OPD

Common problem in children, as well as adults!

Distinguish primary from secondary.

Most headaches get worse with exertion so that’s not a discriminating feature.  Headaches that get worse on standing suggest a CSF leak; worse on lying down suggests a tumour.  See NICE CKS.

Primary

Secondary

Migraine

Common, General paediatrics, Neurology, OPD

International Headache Society 2004 Migraine without aura def:

  • A – at least 5 attacks fulfilling B-D
  • B – lasting 1-72hr
  • C – at least 2 of:
    • unilateral, may be bilateral frontotemporal but not occipital;
    • pulsing;
    • moderate or worse pain;
    • aggravation by routine physical activity eg walking, stairs
  • D – during headache at least 1 of: nausea +/or vomiting, photophobia and phonophobia (which may be inferred from behaviour)
  • E – not attributed to other disorder

Aura – Hemianopia or spreading scintillating scotoma. Note that migraine with aura is a contraindication to treatment with combined oral contraceptives.

Some specific types:

  • Hemiplegic – can be familial or sporadic.  Can be confusion.  Rare to not have headache with it (but then diagnosis perhaps not recognised!?).  Triptans were initially thought to be risky, but more recently good evidence of usefulness and no longer contraindicated in BNFc.
  • Ocular/retinal – blindness or flashing lights, may not be headache.  NOT aura, which is prodromal.  Horner’s syndrome seen.
  • Basilar (also called Bickerstaff’s – but better termed migraine with brainstem aura) – transient dysarthria, vertigo, tinnitus, hearing impairment, diplopia, ataxia, confusion, bilateral paresthesia,
  • Confusional

Pathology

Neuronovascular condition – baseline hyperexcitability in cortex.

Double the risk if you had infant colic, which is not true for tension headache!  Sleep disruption as common factor? [JAMA 2013;309:1607-12]

Several genetic links found eg C677T mutation of the methylenetetrahydrofolate reductase gene (MTHFR), EAAT2. [J Headache Pain. Jan 2012; 13(1): 1–9.  doi:  10.1007/s10194-011-0399-0]

Investigations

Beware Occipital epilepsy!

American Academy of Neurology recommendations are that neuroimaging should be considered in:

  • recent onset of severe headache;
  • change in type of headache;
  • or neurological dysfunction;
  • seizures

Factors

  • Biofeedback and relaxation/stress management are as effective as beta blockers. Indian trial of yoga for migraine showed substantial improvement at 3 months [neurology 2020]
  • Sleep disturbance is associated but not necessarily causal – so recommend good sleep hygiene.
  • Exercise is beneficial.
  • Obesity – clusters with diet, exercise, sleep issues of course.
  • Missing breakfast is a common precipitant.
  • Episodic migraine (without aura) can become chronic (ie 15 days per month or more), but in this case you would always want to exclude medication overuse.
  • Caffeine is linked to headache and also sleep/mood disorder which exacerbates. Withdrawal headache can last as long as a week.
  • Wine is well recognised trigger in adults!
  • Often linked to menstrual cycle.
  • Screen time (>2hrs per day) linked to migraine but not non-migraine headache in French and Sri Lankan students.  Doesn’t necessarily mean reducing screen time helps, of course.  But note eye strain, posture relevant too.  And possibly differences between TV/PC use and mobile devices.
  • Some evidence for magnesium and zinc supplementation

[CurrOpPeds Dec 2004]

Diet

Although popular perception is that migraine is caused or at least triggered by dietary factors, there is a wide variation in reporting of dietary triggers. Certainly migraine is associated with obesity, and dietary habits seem to be as important as specific foods, and there is probably a cycle of inconsistent nutrition and poor control of migraine.

My colleagues talk about 4Cs (chocolate, cheese, coffee, citrus) but I have found no evidence for this.  Awareness of possibility of dietary triggers actually has greater influence on perception of personal triggers than personal experience!  See below.

Some evidence for lipid intake esp PUFA (decreased ingestion of lipids was associated with a decrease in the frequency, intensity, and duration of migraines and a decrease in the use of medication) but confounded by obesity, weight reduction, and changes in nutrient intake.  Another study found reduced migraine spells among children subjected to a diet rich in fibre. Not much evidence for cheese at all! [Nutrition Reviews. 70(6):337-56, 2012 Jun.  UI: 22646127]

Trial of cyanocobalamin, folate, and pyridoxine (2 mg of folic acid, 25 mg vitamin B6, and 400 microg of vitamin B12) in patients with MTHFR gene defects found a reduction of homocysteine levels and improvement of migraines. [Pharmacogenetics and Genomics. 22(10):741-749, October 2012]

Medication

Paracetamol, ibuprofen, and nasal-spray sumatriptan are all effective symptomatic treatments for episodes of migraine (peds sys rv 2005). Migraleve is paracetamol, codeine (8mg), buclizine – for 10yr plus. Paramax, with metoclopramide, for 12 yr plus.  Anti-emetic improves pain killer absorption so potential benefit even if no nausea!

Sumatriptan was previously contraindicated for hemiplegic migraine, but this was probably a theoretical concern, and there is evidence that it works. No caution or contraindication mentioned in BNF now.

Mefenamic acid for menstrual, esp with dysmenorrhea.

CGRP receptor antagonists – olcegepant, telcagepant [not in BNF].  Now erenumab [monthly subcut injections, BNF says specialist use only, minimum 4 migraines per month – SMC approved with restrictions], eptinezumab etc vs same calcitonin gene-related peptide receptor.  Significant improvement in headaches in 40%, about 3 less headache days per month.

For prophylaxis, Pizotifen does not work (grade I evidence, plus makes you fat), flunarizine (CCB) is the most effective (not in BNF), also amitriptyline (dangerous in overdose), propanolol (dizziness, sleep disturbance, depression etc, also dangerous in overdose). Encouraging data (grade IV) for anti-epileptic mediations topiramate, valproate, levetiracetam, zonisamide. Cyproheptadine? Candesartan (anti-hypertensive, in BNF for migraine prevention)?

Always increase preventer dose to maximum before giving up, note that often symptoms worsen after initial benefit.

Current evidence on the efficacy of percutaneous closure of patent foramen ovale (PFO) for recurrent migraine is inadequate in quality and quantity. The evidence on safety shows a small incidence of well-recognised but sometimes serious adverse events, including device embolisation and device prolapse (each reported in less than 1% of patients). Therefore this procedure should only be used with special arrangements for clinical governance, consent and audit or research. [NICE]

Contraception

Combined oral contraceptives are contraindicated in migraine with aura.  But may be useful if menstrual pattern to headaches if no aura.

Prognosis

50% migraine in childhood remits at puberty. Onset in adolescence associated with persistence.

Support

Patient support at Migraine Trust.

Sleep

Common, Community, General paediatrics, OPD

Poor sleep associated with hyperactivity, obesity, poor school performance, depression.  And affects parents, of course!  Caffeine and Propranolol (as used for migraine prophylaxis) affect sleep!

Normal sleep

REM (rapid eye movement) phase is light sleep. Usually in later part of night after deep sleep.  Slow wave (deep) sleep is associated with increased anabolic hormone release, mitotic repair. Higher proportion of sleep in adolescence is slow wave.  60% of newborn sleep is REM.

Recommended sleep duration: [National Sleep Foundation]

  • Newborn 0-3 months: 14-17 hours
  • Infants 4-12 months: 12-15 hours
  • 1-2yrs: 11-14 hours
  • Preschool 3-5yrs: 10-13 hours
  • School age 6-13yrs: 9-11 hours
  • Teenagers 14+: 8-10 hours

Some sources suggest adolescents have increased sleep requirements.

Late insomnia (early morning waking) in depression. Cf early – mood disorders, anxiety (cortisol vs melatonin).

30 mins high intensity exercise is as good as melatonin. But ideally 3hrs before bed time!?

Sleep latency 19 min under 2yrs, 17-19 mins thereafter.

Night wakenings are normal! But parental response varies!

Excessive sweating seen in 11% of children, so considered normal. But beware weight loss, lethargy!  Can also be associated with obstructive sleep apnoea.

Sleep problems

For infants not going to sleep, options are extinction vs gradual retreat. Not appropriate for under 6/12 of age as may affect bonding. No adverse effects otherwise.

Melatonin does not increase total sleep time! Helps prepare brain for sleep – does not induce sleep, as such.  Earlier waking as well!

Nocturnal seizures – stereotyped, multiple in one night, sudden stop and start, mostly after first third of sleep.  Seen in BECTS.

Restless legs associated with iron deficiency!

Benign nocturnal leg pain common in children.

Teenagers generally do have different body clock, but not helped by major changes in bed/wake times at the weekend. Blue light from screens suppresses natural melatonin production besides distraction.

For autism – Hope for autism do not need diagnosis, others do. Waiting times? National Autistic Society page. Arch, Reach websites.

CAMHS won’t prescribe melatonin but do prescribe methylphenidate!?

Bio melatonin 3x the price, not approved by SMC. Modified release melatonin may be useful with or without standard if early waking in night.

Parasomnias

In early part of night, likely to be non REM, cf later in night.

Classic non REM =

  • Confusional arousal – can appear fully awake but don’t make much sense, no recollection in morning.
  • Sleep walking – quite complex behaviours possible (riding a motorcycle!)
  • Sleep terror – worse for partner/parents, as rarely remembered

REM related =

  • REM sleep behaviour disorder – typically violent, dream can often be remembered, can escalate. Can be sexual.
  • Sleep paralysis – up to several minutes, usually terrifying (“like being dead”), often with hallucinations.

Sleep hygiene, then consider melatonin and CBT (stress often provokes non-REM). Benzodiazepines can help non REM but can worsen REM.

Beware Narcolepsy – poor sleep quality at night, then daytime somnolence, plus hypnagogic/hypnapompic hallucinations, sleep paralysis, cataplexy (laughing causes collapse). Genetic, treatable with stimulants.

Support

Posterior urethral valves

General paediatrics, Renal, Surgical

1 in 5000 births.  Mostly failure of Wolffian duct development, rarely failure of urethral canalisation.

2/3 detected antenatally, with distended bladder. If missed, then present with urinary tract infection, abnormal voiding (dribble rather than fountain!) else incontinence (if toilet trained, of course).

Later detrusor failure, tubular dysfunction, renal failure.

Fussy eating

General paediatrics, Nutrition

Hard to define – picky, restricted, faddy? Neophobia important – refusal to try new things. Only really a problem of the developed world… Refusal to eat unhealthy foods is obviously no bad thing…

Actually not much evidence about long term consequences – such studies are hard – poor fibre intake associated with constipation, persistent fussy eating may lead to being underweight, becoming a fussy adult or possibly an eating disorder. Avon longitudinal study (where most of the data comes from) found calorie intake maintained (some studies have found higher calorie intake in fussy eaters) but lower levels of iron, zinc, fibre and vitamin A. Intake of all but Vitamin A were below recommended levels for a substantial proportion of fussy children.

Peak age seems to be around 3yrs. Twin studies suggest highly heritable (due to heritability of sensitivity to bitterness) – associated with having fussy parents too. From an evolutionary perspective, non-mobile infants are only likely to be offered safe foods by their mother; once mobile however, risk of eating poisonous plants or contaminated foods. Hence probably why preference among fussy eaters is for bland flavours and colours, and non slimy textures.

Other risk factors are older mothers, higher maternal educational attainment, lower parity and lower birthweight. More precious children??

Avon longitudinal study found maternal worry about fussy eating at 15 months predicted fussy eating at age 3 (RR=3). Fresh fruit and eating the same meal as a family protective, ready meals increased risk of fussy eating.

Early introduction of vegetables before 6 months helps but goes against WHO guidance…

Australian study showed maternal healthy (adventurous) eating helps.

Parents get very emotional about the lack of variety in their child’s diet or perceived disinterest or refusal to eat. The often “internalise the child’s food intake as a reflection of their own parenting“, whereas choices of what and how much to eat are actually an expression of the child’s emerging autonomy.

Parental pressure to eat (usually fuelled by concerns the child is underweight, which is rarely the case) is associated with fussy eating, not surprisingly, but is potentially a vicious circle. Maternal negative affectivity, internalising problems, sensitivity (ie low tolerance) predicts fussy eating; authoritative parenting style protects [Norwegian studies]. The combination of modelling health eating (which means eating the same food together and not offering alternatives) and not pressuring definitely seems best.

[Caroline Taylor and Pauline Emmet, Bristol 2018]

For extreme refusal

Things to avoid

  • Do not refuse to give high-energy foods, like ice cream, cakes, biscuits and chocolate, in the hope that your child will eat ‘proper’ meals and ‘healthy’ foods.
    Reason:This is not a good way to get your child to eat new foods, and your child might lose weight if you withhold their ‘safe’ foods.
  • Do not try to force your child to eat food.
    Reason:This will make your child even more anxious at mealtimes, and may cause your child to vomit the food back up.
  • Leave long gaps between meals to try to make your child more hungry or hide new foods inside foods that your child already likes.
    Reason: This will make your child less hungry over time, and may lead to weight loss. Some children can very easily detect new tastes and smells, even when hidden in other foods. Your toddler may just stop eating the liked foods.

Things that help

  • Encourage your child to experience different textures through ‘messy’ play every day. Your toddler may find some textures (like Play-Doh) very difficult, so start with textures that they are happy to touch. This may need to be drier consistencies initially, such as rice or lentils. Gradually progress to more messy/wet substances, allowing your toddler to gain confidence. Have plenty of fun and get messy. If you don’t like touching certain textures yourself, or don’t feel comfortable allowing your toddler to make a mess, then why not take them to a playgroup in your area?
    Reason: Many children who are extreme food refusers are very sensitive to touch on the hands and mouth, and so will not even pick up new foods. Messy play helps them to get used to new textures.
  • Give small frequent meals of foods that your child accepts.
    Reason: Some children become very anxious at mealtimes and are sometimes very slow eaters. Small frequent meals will help them to take in the calories that they need.
  • Remember, even children who are extremely faddy eaters usually grow and develop normally, if they are given the foods that they will accept.
    Reason:It is important to keep your child growing well, and these extreme food refusers do grow as we would expect them to if they have enough of the food that they will eat.

Growth Charts

General paediatrics, Nutrition, OPD

Current charts are UK-WHO, which is to say a combination of UK growth cohorts with world wide cohorts.  This is to correct for the low prevalence of breast feeding and high prevalence of obesity in the UK, and assumes that there is little genetic differences in growth.

Downloads and online growth tool at RCPCH.

Usage Tips

Between 37 and 42 get plotted as term.  No centiles for first 2 weeks as dip expected.  One in 5 still below birth weight at 2 weeks, only one in 50 will be 10% below or more.  Still mainly well, but suggests feeding problem worthy of further assessment, and in a few there will be an otherwise occult pathological condition eg cardiac or metabolic disorder.

Preterms get plotted on both Preterm section of chart AND day 0!  Because assessing early growth works best on day 0 centile, whereas later growth more likely to be related to preterm centile.  Plot after birth on preterm section until you hit the end (42 weeks) then continue on to main 0-1yr chart, plotting a point for calendar age but adding arrow indicating gestational age.   Otherwise unclear whether corrected or not.

Children up to age 2 get weighed without clothes or nappy.  From 2, minimal clothing and no shoes.  Height is hard! Only act on several measurements that appear consistent!